What are the nursing considerations for digoxin (digitalis glycoside)?

From the Guidelines

Nursing considerations for digoxin require careful monitoring of vital signs, particularly heart rate, which should remain above 60 beats per minute in adults, and serum digoxin levels should be maintained between 0.5 to 0.9 ng/mL, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1. When administering digoxin, it is crucial to assess apical pulse for a full minute and withhold the medication if the pulse is below 60 or irregular, notifying the physician immediately. Some key points to consider include:

• Monitoring serum digoxin levels regularly to avoid toxicity, which can occur at levels above 2.0 ng/mL 1.
• Being vigilant for signs of digoxin toxicity, including nausea, vomiting, visual disturbances, confusion, and cardiac arrhythmias.
• Assessing for factors that increase toxicity risk, such as hypokalemia, hypomagnesemia, hypercalcemia, renal impairment, and drug interactions with medications like amiodarone, verapamil, and certain antibiotics 1.
• Monitoring electrolytes closely, especially potassium, as low potassium levels significantly increase toxicity risk.
• Administering digoxin at the same time each day, preferably with food to reduce GI upset, and ensuring accurate dosing, particularly with liquid preparations.
• Providing patient education on pulse monitoring, recognizing toxicity symptoms, maintaining consistent dietary potassium intake, and avoiding over-the-counter medications without consultation. It is also important to note that digoxin has a narrow therapeutic index, meaning the difference between therapeutic and toxic doses is small, which necessitates this careful monitoring approach 1.

From the FDA Drug Label

Nursing Mothers Studies have shown that digoxin concentrations in the mother’s serum and milk are similar However, the estimated exposure of a nursing infant to digoxin via breast feeding will be far below the usual infant maintenance dose. Pediatric Use Newborn infants display considerable variability in their tolerance to digoxin Premature and immature infants are particularly sensitive to the effects of digoxin, and the dosage of the drug must not only be reduced but must be individualized according to their degree of maturity. Geriatric Use The majority of clinical experience gained with digoxin has been in the elderly population This experience has not identified differences in response or adverse effects between the elderly and younger patients.

The nursing considerations for digoxin include:

• Monitoring serum electrolytes and renal function in patients receiving digoxin 2
• Caution when administering digoxin to nursing women, as digoxin is excreted in breast milk, although the estimated exposure to the infant is expected to be low 2
• Individualized dosage for premature and immature infants, as they are particularly sensitive to the effects of digoxin 2
• Careful dose selection for elderly patients with decreased renal function, as they are at higher risk of toxic reactions to digoxin 2

From the Research

Nursing Considerations for Digoxin

The nursing considerations for digoxin (digitalis glycoside) are crucial due to its narrow therapeutic index and potential for toxicity. Key considerations include:

• Monitoring for signs of toxicity, such as nausea, vomiting, confusion, and arrhythmias 3, 4
• Evaluating dosage patterns and monitoring patterns to prevent possible toxic reactions 3
• Assessing serum creatinine and potassium levels, as hypokalemia can increase the risk of digoxin toxicity 5
• Managing potential drug interactions with digoxin, such as diuretics, which can contribute to hypokalemia 3, 5
• Being aware of the importance of correct dosing of digoxin-specific antibody fragments (digoxin-Fab) in cases of digoxin toxicity, as calculated full neutralizing doses may not always be necessary 6

Monitoring and Management

Nurses should:

• Identify all patients receiving digoxin and evaluate their dosage patterns 3
• Monitor serum digoxin levels, as well as electrolyte levels, particularly potassium 3, 5
• Be prepared to manage potential toxic reactions, including the administration of digoxin-Fab in severe cases 6, 7
• Provide education to patients on the importance of adhering to their prescribed digoxin regimen and reporting any signs of toxicity 3

Special Considerations

In cases of acute digoxin intoxication, nurses should:

• Be prepared to administer stomach lavage, laxatives, and correct cardiac arrhythmias 4
• Consider the use of temporary pacemaker therapy for patients with high atrioventricular block, and hemoperfusion for patients with renal insufficiency 4
• Monitor patients closely for signs of toxicity and be prepared to intervene quickly in cases of severe toxicity 3, 4